Incorporating Social and Behavioral Determinants

of Health in Patient Care

HIMSS Nursing Informatics PreConference, February 11, 2019

Marisa L. Wilson DNSc MHSc RN-BC CPHIMS FAMIA FAAN, Associate Professor

The University of Alabama at Birmingham School of Nursing

Marisa L. Wilson DNSc MHSc RN-BC CPHIMS FAMIA FAAN

Has no real or apparent conflicts of interest to report.

Conflict of Interest

• Introduction

• Describe national momentum towards inclusion of SDOH data

• Examine potential sources of SDOH data

• Assess strategies for incorporating SDOH data

• Review optimization strategies for the inclusion of SDOH data

• Summarize lessons learned and issues

• Solicit audience lessons

• Questions?

Agenda

• Introduction

• Describe national momentum towards inclusion of SDOH data

• Examine potential sources of SDOH data

• Assess strategies for incorporating SDOH data

• Review optimization strategies for the inclusion of SDOH data

• Summarize lessons learned and issues

• Solicit audience lessons

• Questions?

Agenda

• Describe the importance of social and behavioral determinants of

health to patient care

• Provide on outline for incorporating social and behavioral

determinants of health information into patient care and

documentation.

• Describe strategies for optimizing health IT systems to capture

and use information about social and behavioral determinants of

health of individuals

Learning Objectives

• Provision 8 – The nurse collaborates with other health professionals

and the public to protect human rights, promote health diplomacy,

and reduce health disparities.

– Advances in technology, genetics, and environmental science

require robust responses from nurses working together with

other health professionals for creative solutions and

innovative approaches that are ethical, respectful of

human rights, and equitable in reducing health

disparities.

– Through community organizations and groups, nurses

educate the public, facilitate informed choice, identify

conditions and circumstances that contribute to illness,

injury, and disease, foster healthy life styles, and

participate in institutional and legislative efforts to protect

and promote health.

ANA Code of Ethics for Nurses

with Interpretive Statements

SDOH: Contributors to Health

Creative Commons: http://www.goinvo.com/features/determinants-of-health/

• Social factors account for 25-60 percent of deaths in the United

States in any given year according to various meta-analyses.

(Hieman & Artiga, 2015)

• Up to 70 percent of a person’s overall health is driven by these

social and environmental factors and the behaviors influenced by

them.

(Schroeder, 2007)

SDOH Impact

Definitions of Social Behavioral Determinants of Health (SDOH)

• Complex, integrated, and overlapping social structures and

economic systems that are responsible for most health inequities.

• These determinants include social environment, physical

environment, health services, and structural and societal factors.

(CDC)

www.cdc.gov/nchhstp/socialdeterminants/definitions.html

• The conditions in which people are born, grow, live, work and age.

(WHO)

https://www.who.int/social_determinants/en/

National Momentum Towards Inclusion

• WHO Closing the Gap in a Generation (2008)

https://www.who.int/social_determinants/final_report/csdh_finalr

eport_2008.pdf

• IOM Recommended Social and Behavioral Domains and

Measures for Electronic Health Records (2014)

http://nationalacademies.org/HMD/Activities/PublicHealth/Socia

lDeterminantsEHR.aspx

Landmark Documents

• Federal and State Initiatives

– 2016 Center for Medicare and Medicaid (CMMI) established

by ACA announced Accountable Health Communities

connecting Medicare and Medicaid beneficiaries with

community services. CMMI awarded 32 grants.

• Medicaid Initiatives

– Delivery and payment system reform linking health care and

social needs

– Medicaid Managed Care Organizations engaging in

activities to address SDOH.

• Provider Activities

– Not for profit hospitals required to conduct community heath

needs assessments once every three years and to develop

strategies

Initiatives to Address SDOH

What are the social determinants of health?

Income

and Income Distribution

Stress

Education

Social Exclusion

Unemployment and Job Security

Safety

Food Insecurity/Security

Domestic Violence

Housing

Incarceration

Health Services

Race

and Ethnicity

Transportation

Veteran Status

Environment

Refugee Status

World Health Organization and Institute of Medicine

• Community level determinants

• Individual level determinants

Sources of SDOH Data

• Zip code is more important than genetic code.

Robert Wood Johnson Foundation, 2009

Community Level SDOH Data

• Useful at the system level

• Can enhance performance of predictive models

• Interest to researchers who want to determine the role of

community context in health

• Tools for community generated SDOH

• City Health Dashboard

https://www.cityhealthdashboard.com

• County Health Rankings and Roadmaps

http://www.countyhealthrankings.org/explore-health-

rankings#county-select-38

• CDC Data Set Directory of Social Determinants of Health at

the Local Level

https://www.cdc.gov/dhdsp/docs/data_set_directory.pdf

Age

Income and Earnings

Race and ethnicity

Ancestry

Labor Force status

School enrollment

Commuting Patterns

Language spoken

Gender

Disability

Marital status

Transportation to work

Educational Attainment

Mobility

Type of work

Employer Type

Nativity

Veterans disability

Fertility

Number of children

Wealth

Food Stamps

Other Income

Well being

Household and Family

Perceived health status

Basic needs, consumer

durables

Housing value

Poverty

Crime

Potential Census Bureau Data

• Securing appropriate data

• Attributing community data to an individual

• Determining the lowest appropriate level of measurement

• Engaging big data techniques

• Using predictive analytics tools,

• Learning new tools - heat maps

• Looking upstream with available data

Issues Related to Community Level

SDOH

• Collected through screenings, checklists, or surveys

• Can be embedded into the EHR, or a tablet, or PHR, or on paper

• Vendors have added SDOH screenings into EHRs

– Intimate Partner Violence

– Social Isolation

– Alcohol and Tobacco Use

– Depression

– Financial Resources

– Food, transport and housing insecurity

Individual Level SDOH Data

• Protocol for Responding to and Assessing Patients’ Assets, risks,

and Experiences (PRAPARE) from the

15 core and 5 supplemental question

Structured data

Administered by a clinician or staff

http://www.nachc.org/research-and-data/prapare/toolkit/

• CMS Accountable Health Communities Health Related Social

Needs Screening Tool

Medicare and Medicaid recipients

Self administered

Covers 5 domains with 8 supplemental domains

https://innovation.cms.gov/Files/worksheets/ahcm-screeningtool.pdf

Examples of Individual Level Tools

• Social Interventions Research and Evaluation Network (SIREN)

Collects, summarizes, and compares tools for adults and

pediatric populations

Has compiled information on the most widely used tools

https://sirenetwork.ucsf.e https://sirenetwork.ucsf.edu/tools-

resources/mmi/screening-tools-comparison/adult-nonspecific

du/about-us

Compilations and Comparisons of SDOH

Tools

AHC

Tool

HealthBegi

Health

Leads

MLP

IHELLP

Medicare

Total Health

Assessment

Questionnai

NAM

Domains

PRAPARE

WellRx

Your

Current

Life

Situation

iHELP SEEK SWYC We Care

• Who is the population – Adults? Pediatric?

• Do you need a targeted tool?

Interpersonal Violence screening in pregnant women

Adverse Childhood Experiences (ACE) for children

Homelessness

• Are the tools validated?

• Is there a cost to use the tool?

• Are the assessments and measures standardized and coded for

reuse?

https://loinc.org/sdh/

Issues with Individual SDOH Tools

Triple S of SDOH Data

• Systematic SDOH collected in all encounters

• Structured SDOH via tools

• Standardized SDOH using datasets to allow for aggregation and

interoperability

• ICD-10-CM codes included in categories Z55-Z65

Z55 Health literacy (illiteracy, schooling…)

Z56 Employment and unemployment (work environment)

Z57 Occupational exposure (radiation, dust, smoke…)

Z59 Housing and economic circumstances (homeless, inadequate

housing…)

Z60 Social environment (life transitions, living alone…)

Z62 Upbringing (inadequate parental supervision, overprotection…)

Z63 Primary Support Group (family member absence, disappearance,

death, stress…)

Z64 Psychosocial Circumstances (unwanted pregnancy, discord…)

Z65 Other Psychosocial (convictions, imprisonment, crime…)

PRAPARE template uses the Z codes

https://images.magnetmail.net/images/clients/AHA_MCHF/attach/2018/April/valueinitiativeicd10odesdoh0418.p

Standards and Coding for SDOH Data -

ICD

• Social, psychological and behavioral observations

• 80216-5 panel data from:

2015 Health IT Certification Criteria

Patient Health Questionnaire (PHQ-2)

Alcohol Use Disorder Identification Test – Consumption

(AUDIT-C)

Humiliation, Afraid, Risk, and Kick (HARK)

National Health and Nutrition Examination Survey (NHANES)

• 82152-0 panel data from:

Adverse Childhood Events (ACE)

Behavioral Risk Factor Surveillance System (BRFSS)

https://s.details.loinc.org/LOINC/80216-5.html?sections=Comprehensive

Standards and Coding for SDOH Data -

LOINC

• Transportation

• Uber Health removing transportation as a barrier

https://www.uber.com/newsroom/uber-health/

Creative Responses to SDOH

• UABSON’s nurse managed PATH clinic

• UABMC Heart Failure Clinic

• Community Food Bank of Central Alabama

• Food Banks as partners in. health promotion

http://www.rootcausecoalition.org/wp-content/uploads/2016/07/Food-Banks-as-

Partners-in-Health-Promotion-FINAL.pdf

Food Insecurity

• Utah Alliance for Determinants of Health (Intermountain)

https://intermountainhealthcare.org/blogs/topics/transforming-

healthcare/2018/07/new-alliance-seeks-to-address-the-social-

determinants-of-health/

• Baltimore Accountable Health Community – the only health

department to receive a CMMI grant

https://health.baltimorecity.gov/sites/default/files/health/attachments/

Baltimore%20Accountable%20Health%20Community%20Overview.

pdf

Alliances to Address SDOH

• Integration of SDOH across primary care to transitions workflows

• Creation of communications’ pathways between hospital and home

• Systems approach to managing complex, chronically ill patients

• Relies on tools developed using interoperability standards

• Incorporates claims based risk stratification and an assessment of SDOH

using the Patient-Centered Assessment Method (PCAM)

• PCAM – 12 item Likert scale tool measuring 4 domains: physical and

mental health, social support, health literacy, and engagement with

services

• SDOH incorporated into a reworked informational and clinical workflow

• Operationalized through a collaboration of University of Buffalo SON,

Department of Family Medicine, a RHIO, and a PCMH

(Hewner, Casucci, Sullivan et al, 2017)

Integrating Social Determinants

across Transitions

• Identify the population and evidence supported purpose

• Determine community or individual level data needs

• If individual is it clinician or patient entered

• Decide if data will be collected as part of a flowsheet, through

portal, or on paper

• Ensure that SDOH data is incorporated and reported

• Use clinical decision support tools (rosters, alerts)

• Identify and create referral database

• Create referral ordering functions

• Use coded, standardized tools

• Create data linkages and closed loops

Optimizing the Collection of SDOH

• Creating actionable SDOH data is vital

Social determinants referrals

Making a match

Workflow implications

Closed loop reporting – Do we know they got the service?

Start ups are addressing the loop:

NowPow

Healthify

Vendor responses

Optimizing by Closing the Loop

• Documentation burden

• Implementation is challenging – can you act on the data?

• Clinician engagement

• Support staff engagement

• Requires input from other professionals (SW, OT, PT, etc)

• Operational challenges – where is the ROI?

• No closed loop between care and services

• Patients may not want to answer or want help

• Screenings take time – referrals can be burdensome

• Interpreters may be needed

• Fragmentation of data

• Training, training, training

Lessons Learned

• Centers for Disease Control and Prevention

https://www.cdc.gov/nchhstp/socialdeterminants/resources.html

• Institute of Medicine

http://nationalacademies.org/HMD/Activities/PublicHealth/Socia

lDeterminantsEHR.aspx

• National Association of Community Health Centers

http://www.nachc.org/research-and-data/prapare/

• Social Interventions Research and Evaluation Network (SIREN)

University of California, San Francisco

https://sirenetwork.ucsf.edu

Resources

Marisa L. Wilson DNSc MHSc RN-BC CPHIMS FAMIA FAAN

mwilsoa@uab.edu

@UABSON

UAB School of Nursing

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Questions and Thank You